Gynecologic and Obstetric Emergencies
Patterns of Menstrual Bleeding
1. Normal cycle: every 28 days ± 5 days with a duration of 3 to 6 days
2. Normal menstrual flow: 80 mL or three to five pads or tampons per day with a duration of 3 to 5 days
3. Menorrhagia: extended duration
4. Metrorrhagia: continuous duration or with no identifiable pattern
5. Menometrorrhagia: increased quantity and duration
6. Hypermenorrhea: increased quantity
7. Intermenstrual spotting: small amounts of vaginal bleeding that may occur before or after menstruation or midcycle
Vaginal Bleeding Associated with Pregnancy
History
1. Any history of prior ectopic pregnancy, salpingitis, pelvic inflammatory disease, tubal surgery, or use of fertility agents or intrauterine device (IUD) should increase clinical suspicion.
2. Prior bilateral tubal ligation does not exclude the diagnosis.
3. History is usually suggestive of early pregnancy and includes nausea, amenorrhea, and breast tenderness.
4. A prior seemingly normal or abnormal menstrual period is also possible.
Signs and Symptoms
1. An ectopic pregnancy may rupture as early as 5 weeks’ gestation but most commonly ruptures after 7 weeks’ gestation.
2. Ectopic rupture is generally preceded by abnormal vaginal bleeding and unilateral lower abdominal pain.
3. A triad exists of vaginal bleeding, adnexal mass, and lower abdominal pain that is usually unilateral and may radiate to the shoulder.
4. Cervical motion tenderness may be present on pelvic examination.
5. Dizziness, syncope, and unstable vital signs may be present if blood loss is substantial.
6. Rebound tenderness and rigidity are signs of rupture.
7. Any patient with positive pregnancy test results and lower abdominal pain, usually unilateral, should be assumed to have an ectopic pregnancy until proven otherwise.
a. This test is currently sensitive enough to detect levels of urinary β-human chorionic gonadotropin (β-hCG) as low as 20 milliunits/mL from the third to fourth week after the first day of the last menstrual period.
b. This test should be included in remote expedition medical supplies. To ensure adequate performance of the test, use a test with an internal reference.
Spontaneous Abortion
Early pregnancy loss before 20 weeks’ gestation
Signs and Symptoms
1. History suggestive of early pregnancy, including late or missed period and breast tenderness
2. Positive urine pregnancy test results with above signs and symptoms
3. Spontaneous abortion presents as abnormal vaginal bleeding, followed by uterine cramping.
4. Bleeding can vary from dark red spotting to bright red clots.
Treatment
1. Unless a pretrip ultrasound examination has verified an intrauterine pregnancy, immediately evacuate the patient to rule out ectopic pregnancy.
2. Keep the patient at “bed rest” if possible.
3. Direct all field treatment to volume replacement.
4. Evacuation of uterus to prevent further hemorrhage or infection will be necessary once transported to medical facility.
5. Treatment of septic abortion will involve broad-spectrum intravenous antibiotics (see Appendix H).
6. Treat for shock until evacuated (see Chapter 13).
7. Under wilderness conditions, control of significant maternal hemorrhage accompanying miscarriage may be difficult. Once the uterus is empty, uterine involution, spontaneous or aided by uterine massage, is usually sufficient to impede bleeding from the implantation site. In the absence of the ability to perform curettage, treatment with methylergonovine, 0.2 mg PO or IM, can enhance uterine contractions, accelerate expulsion of POC, and promote uterine involution to maintain hemostasis while plans are being made for evacuation of the patient. Methylergonovine should not be used in persons with hypertensive disorders or vascular disease unless the benefits outweigh the risks of generalized vasoconstriction. As an alternative, carboprost tromethamine 250 mcg IM, or misoprostol 100 mcg PO or vaginally, can be administered to stop uterine bleeding with less risk for cardiovascular compromise.
Placental Abruption
1. Rupture of the placenta from the wall of the uterus
2. Separation partial to complete
3. History of painful bleeding in late pregnancy or after trauma
Bleeding Not Associated With Pregnancy
Abnormal Uterine Bleeding in a Nonpregnant Woman
1. Includes bleeding between normal menstrual cycles, change in normal pattern of menstrual cycle, increased or decreased amount of menstrual bleeding
2. Consider other systemic or structural processes:
a. Complications of pregnancy: threatened, incomplete, or spontaneous abortion; ectopic or molar pregnancy
b. Infectious: vaginitis, cervicitis, pelvic inflammatory disease (PID)
d. Medications: aspirin, warfarin, oral contraceptives, tricyclic antidepressants, and major tranquilizers
e. Systemic illness: hepatic, thyroid, and adrenal dysfunction
f. Polycystic ovary syndrome and other endocrinopathies
g. Anatomic lesions: fibroids, polyps, ovarian cysts, endometriosis, endometrial hyperplasia, neoplasm
k. Common in perimenopausal women
l. Common in adolescence secondary to immaturity of the hypothalamic-pituitary-ovarian axis
Treatment
1. Perform a urine pregnancy test to rule out pregnancy.
2. In the wilderness, modern, low-dose oral contraceptive pills can be safely used whether the bleeding is caused by estrogen or progestin deficiency or excess.
3. High doses of oral contraceptive pills of the combination monophasic type, such as Lo/Ovral (norgestrel, 0.3 mg, and ethinyl estradiol, 30 mcg), are usually effective.
4. The usual dose for this purpose is three pills per day for 7 days (i.e., one complete pack over a single-week course).
5. Other options include conjugated estrogen or medroxyprogesterone acetate (Table 31-1).
6. Bleeding is typically controlled within 12 to 36 hours.
7. Side effects such as nausea, headache, fluid retention, and depression sometimes occur.
8. After completion of the oral contraceptive pills (i.e., after 7 days), expect significant withdrawal bleeding.
